Compensation Report Form. This is a Alaska form and can be use in Workers Comp.
Tags: Compensation Report, 07-6104B, Alaska Workers Comp,
your information. Keep it for EMPLOYEE: This report is forinformation about your rights your records. Read important on back. ALASKA DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT Alaska Workers' Compensation Board P.O. Box 115512, Juneau AK 99811-5512 AWCB Case Number Only COMPENSATION REPORT 1. Employee's Name (Last, First, Middle Initial) 2. Insurer Claim Number 3. Injury Date 4. Address 5a. 6. Social Security Number City State Zip Code Single 5b. Number of Dependents Married (AWCB Use Only) Telephone 8. Employer 9. Insurer/Adjusting Company 10. Address 7. Birth Date 11. Address City State Zip Code Telephone City State Zip Code Telephone 12. COMPENSATION RATE --COMPLETE FOR INITIAL PAYMENT OR RATE CHANGE Employee's wages were calculated: a. Weekly = $ (weekly earnings) gross weekly earnings at time of injury (attach wage documents). b. Monthly = $ c. Yearly = $ (monthly earnings) x 12/52 = $ gross weekly earnings (attach wage documents). $ (yearly earnings) ÷ 52 = gross weekly earnings (attach wage documents). d. Day, hour, or output = earnings during either of the two calendar years immediately preceding the injury, whichever is most favorable to the employee gross weekly earnings (attach wage documents). e. Worked less than 13 calendar weeks immediately before injury = $ $ earnings ÷ 13 = ÷ 50 = $ $ gross weekly earnings (attach wage documents). f. Wages not fixed at time of injury, explain how earnings determined: g. By the week or by the month, and employment is exclusively Seasonal/Temporary: = earnings for 12 calendar months immediately preceding date of injury $ ÷ 50 = gross weekly earnings; h. 2 employers or more, use applicable methods above. i. Minor, apprentice, or trainee. j. Volunteer policeman, etc. 13. k. Offset: Social Security (#39) or 155(i) (#40) (attach wage documents). l. Paid $110 minimum, explain b. Gross Earnings a. Alaska TTD, PTD, Death Gross Weekly Earnings Weekly Rate* Maximum or Minimum Weekly Rate* Maximum or Minimum - Tax & FICA x 80% = d. Weekly TTD Rate c. Alaska TPD Offset 41K e. Out-of-state TTD, PTD, Death f. Alaska TTD Rate 14. a. INITIAL PAYMENT b. SIF PAYMENT ONLY Knowledge Date: g. RESUMPTION 15. a. Payment Date Weekly Earnings Capacity - Tax & FICA x 80% = -( COLA Ratio x c. TERMINATION )= COLA Weekly Rate Date Left Alaska %= e. RATE CHANGE f. TYPE CHANGE d. SUSPENSION h. OTHER (Explain) b. Type c. From d. Through e. Weeks & Days f. Weekly Rate (If additional space is needed, use chart on reverse.) TOTAL % of $177,000 Whole Person = $ 16. Impairment Rating: 17. g. Total Amount Permanent impairment compensation was paid in a lump sum. (Enter amount in No. 15 and 16.) If permanent impairment benefits not paid in a lump sum, enter date Employee requested reemployment benefits. 18. a. Date Disability Began b. First Payment Date Date: 19. Date Disability Ended 20. TURN OVER AND COMPLETE ITEM 20 ON REVERSE. REASON FOR SUSPENSION, TERMINATION, RATE CHANGE, TYPE CHANGE, OR NONPAYMENT. 21. Returned to Work At New Job Date: At Same Job 22. Released for Work 23. Medical Stability 24. Compromise and Release Date: 25. C.O.L.A. 26. Controversion (Attach 07-6105) 28. Board Order Occupation Regular Work 27. Recomputation Weekly Pay Rate $ Modified Work 29. Other I certify that I have mailed the original of this report to the employee at the address above and a copy to the Alaska Workers' Compensation Board 30. Name and Title of Person Submitting Report (Type or Print) 31. Signature 33. Address (If Different From No. 11) City Form 07-6104b (Rev 04/2011) EXPLANATIONS AND INSTRUCTIONS ON BACK 32. Date State Zip Code Telephone * From AWCB Tables American LegalNet, Inc. www.FormsWorkFlow.com 35. Report Date 34. Employee's Name (Last, First, Middle Initial) 20. a. Employee Attorney Fees $ b. Late Report Penalties $ c. Employer Attorney Fees $ e. Second Injury Fund $ d. Medical $ f. Reemployment Plan Cost $ g. Reemployment $ h. Interest $ SIF Check Attached i. Other (Explain) 36. a. Payment Date $ b. Type c. From d. Through e. Weeks & Days f. Weekly Rate g. Total Amount FRONT PAGE TOTAL TOTAL 37. SOCIAL SECURITY OFFSET. (Applies only to some recipients of Social Security Benefits.) a. Social Security Retirement or Survivors Benefits (AS 23.30.225(a)). How the reduced weekly compensation was figured: (1) SS Monthly Benefit SS Weekly Benefit Reduction (2) Weekly Rate x 12/52 = x 1/2 = b. Social Security Disability Benefits (AS 23.30.225(b)). How the reduced weekly compensation rate was figured: (1) SS Monthly Benefit SS Weekly Benefit (2) Gross Weekly Earnings Max. Weekly Payment x 12/52 = x 80% = Reduction - Reduced Weekly Rate = SS Weekly Benefit - Reduced Weekly Rate = 38. Remarks 39. EXPLANATION AND ABBREVIATIONS a. Suspension. Item 14d means the employer/insurer has stopped compensation payments expecting to pay more compensation later (usually the difference between the minimum and the documented rate). See paragraph 40a below for effect on medical benefits. b. Termination. Item 14c means the employer/insurer has stopped compensation payments with the belief all compensation due has been paid. See paragraph 40a below for effect on medical benefits. c. In Item 15b, the following abbreviations means the following types of disability: Dth = Death Benefits (Attach 07-6118) TTD = Temporary Total Disability TPD = Temporary Partial Disability PTD = Permanent Total Disability PPI = Permanent Partial Impairment 41 K = Reemployment 25% = 25% Late Payment Penalty d. Knowledge Date under Item 14g means the date the employer/insurer learned about the employee's resumed disability or PPI rating. e. SIF in Items 14b and 20e means Second Injury Fund. The insurer/employer makes this payment directly to the Alaska SIF, not the employee. SIF payments must be attached to the Board's annual report. The SIF payment does not affect the amount of compensation an employee receives. 40. TO EMPLOYEE (or other claimants in the case of death): READ CAREFULLY a. This report means the insurer/employer has begun, stopped or changed your compensation payments. The insurer/employer should continue to pay for medical treatment for your injury for at least two years after your injury date. Although the law lets the insurer/employer stop medical payments two years after your injury date, you may file a written claim asking the Alaska Workers' Compensation (AWC) Board to authorize additional medical payments for treatment necessary to your recovery. b. YOU HAVE TWO YEARS FROM THE DATE OF THE COMPENSATION PAYMENT TO FILE A WRITTEN CLAIM FOR ADDITIONAL COMPENSATION PAYMENTS. c. If the AWC Board has issued a decision regarding your claim, you have one year from the date of the Board's order to file a written claim for a modification because of a change of condition or a mistake. If you have settled your claim by a compromise and release agreement which was approved by the AWC Board and later want to claim more benefits, contact the nearest AWC Board office for information. Attempts to get more benefits after an agreement seldom succeed. d. IF YOU BELIEVE THIS REPORT CONTAINS MISTAKEN INFORMATION, IF PAYMENTS HAVE STOPPED AND YOU CANNOT WORK BECAUSE OF YOUR INJURY, OR IF YOU HAVE QUESTIONS, CONTACT THE PERSON WHO SUBMITTED THE REPORT AT THE PHONE NUMBER OR ADDRESS GIVEN ON THE FRONT OF THIS REPORT. IF YOU AND THAT PERSON CANNOT AGREE, OR IF YOU STILL HAVE QUESTIONS, CONTACT THE NEAREST AWC BOARD OFFICE. SEND COPIES OF YOUR WAGE DOCUMENTS TO THE INSURER/EMPLOYER: DO NOT SEND THEM TO THE AWC BOARD. ALASKA WORKERS' COMPENSATION BOARD Anchorage 3301 Eagle Street, Suite 304 Anchorage AK 99503 Telephone: 907-269-4980 Form 07-6104b (Rev 04/2011) Fairbanks 675 Seventh Avenue, Station K Fairbanks, AK 99701-4586 Phone: 907-451-2889 Juneau P.O. Box 115512, Juneau AK 99811-5512 1111 W 8th St Rm 305, Juneau AK 99801 Telephone: 907-465-2790 American LegalNet, Inc. www.FormsWorkFlow.com